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Recommendations Summary

DM: Protein Intake and Protein Intake for Diabetic Kidney Disease (DKD) (2015)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    DM: Educate on Protein Intake and Hypoglycemia in Adults with Diabetes

    The registered dietitian nutritionist (RDN) should educate adults with diabetes that adding protein to meals and snacks does not prevent or assist in the treatment of hypoglycemia. Ingested protein appears to increase insulin response without increasing plasma glucose concentrations; therefore, carbohydrate sources high in protein should not be used to treat or prevent hypoglycemia.


     

    Rating: Fair
    Imperative

    DM: No Protein Restriction for Diabetic Kidney Disease (DKD)

    For adults with diabetes and diabetic kidney disease (DKD), the registered dietitian nutritionist (RDN) does not need to prescribe a protein restriction. While research reports mixed results regarding the effects of the amount of protein on fasting glucose levels and A1C, independent of weight loss, in adults with type 1 diabetes and type 2 diabetes and DKD, there was no significant impact of protein intake (ranging from 0.7g to 2.0g per kg per day) on GFR. 

    Rating: Strong
    Conditional

    DM: Type of Protein and Diabetic Kidney Disease (DKD)

    The registered dietitian nutritionist (RDN) should advise adults with type 2 diabetes and diabetic kidney disease (DKD) that the type of protein (vegetable-based vs.animal-based) will not have a significant effect on GFR. However, there may be an effect on fasting glucose levels and proteinuria. While one study reports a positive impact of soy protein compared to animal protein on proteinuria and fasting glucose levels, independent of weight loss, in adults with type 2 diabetes and DKD, there was no significant impact of soy protein consumption on GFR. 

    Rating: Weak
    Conditional

    • Risks/Harms of Implementing This Recommendation

      None.

    • Conditions of Application

      The recommendations DM: No Protein Restriction for Diabetic Kidney Disease (DKD) and DM: Type of Protein and Diabetic Kidney Disease (DKD) apply to adults with diabetes and diabetic kidney disease (DKD).


       

    • Potential Costs Associated with Application

      Costs of MNT sessions and reimbursement vary; however, MNT sessions are essential for improved outcomes.

    • Recommendation Narrative

      • Research reports mixed results regarding the effects of the amount of protein (ranging from 0.8g to 2.0g per kg per day) on fasting glucose levels and A1C, independent of weight loss, in adults with type 1 diabetes and type 2 diabetes and diabetic kidney disease (Raal et al, 1994; Hansen et al, 2002; Velazquez et al, 2008). Grade III
      • Research reports that the amount of protein (ranging from 0.7g to 2.0g per kg per day) had no effect on GFR, independent of weight loss, in adults with type 1 diabetes and type 2 diabetes and diabetic kidney disease. No studies reported on proteinuria (Robertson et al, 2007; Velazquez et al, 2008). Grade I
      • There were no studies identified regarding the relationship of differing amounts of protein, independent of weight loss, on insulin levels (exogenous/endogenous) in adults with type 1 diabetes and type 2 diabetes. Intervention studies are needed regarding the impact of differing amounts of protein on insulin levels in adults with diabetes. Grade V
      • One study reports a positive impact of soy protein compared to animal protein on proteinuria, independent of weight loss, in adults with type 2 diabetes and diabetic kidney disease (Azadbakht et al, 2008). There was no significant impact of soy protein consumption on glomerular filtration rate.  There were no studies identified in adults with type 1 diabetes. Additional intervention studies are needed regarding the impact of differing types of protein on diabetic kidney disease in adults with diabetes.  Grade III
      • One study reports a positive impact of soy protein compared to animal protein on fasting glucose levels, independent of weight loss, in adults with type 2 diabetes and diabetic kidney disease (Azadbakht et al, 2008). No studies were identified that reported on A1C or that included adults with type 1 diabetes. Additional intervention studies are needed regarding the impact of differing types of protein on glycemia in adults with diabetes. Grade III
      • There were no studies identified regarding the relationship of differing types of protein (vegetable-based vs. animal-based), independent of weight loss, on insulin levels (exogenous/endogenous) in adults with type 1 diabetes and type 2 diabetes. Intervention studies are needed regarding the impact of differing types of protein on insulin levels in adults with diabetes. Grade V

      From the 2013 American Diabetes Association Nutrition Therapy Recommendations

      • For people with diabetes and no evidence of diabetic kidney disease, evidence is inconclusive to recommend an ideal amount of protein intake for optimizing glycemic control or improving one or more CVD risk measures; therefore, goals should be individualized. Grade C
      • For people with diabetes and diabetic kidney disease (either microalbuminuria or macroalbuminuria), reducing the amount of dietary protein below usual intake is not recommended because it does not alter glycemic measures, cardiovascular risk measures, or the course of GFR decline. Grade A
      • In individuals with type 2 diabetes, ingested protein appears to increase insulin response without increasing plasma glucose concentrations. Therefore, carbohydrate sources high in protein should not be used to treat or prevent hypoglycemia. Grade B

      From the 2015 American Diabetes Association Standards of Medical Care in Diabetes

      Foundations of Care: Education, Nutrition, Physical Activity, Smoking Cessation, Psychosocial Care and Immunization

      In individuals with type 2 diabetes, ingested protein appears to increase insulin response without increasing plasma glucose concentrations. Therefore, carbohydrate sources high in protein should not be used to treat or prevent hypoglycemia. Grade B

      Microvascular Complications and Foot Care

      For people with diabetic kidney disease, reducing the amount of dietary protein below the recommended daily allowance of 0.8g per kg per ay (based on ideal body weight) is not recommended because it does not alter glycemic measures, cardiovascular risk measures or the course of GFR decline. Grade A

    • Recommendation Strength Rationale

      • Conclusion Statements in support of these recommendations were given Grades I, III and V
      • The 2013 American Diabetes Association Nutrition Therapy Recommendations received Grades A, B and C
      • The 2015 American Diabetes Association Standards of Medical Care in Diabetes received Grades A and B.

    • Minority Opinions

      Consensus reached.